Who measures carbon monoxide?

[KellyBracket]

The RAD-57 oximeter is pretty popular, and the new LP has it built in (as an option). But how are people using this information?

In particular, are people using this in rehab at fires, checking FFs before they are "cleared" to return to duty?

I've seen so different permutations, but it looks like > 15% is a guaranteed transport in many systems, whereas lower numbers are handled differently.

 

[MonkeyArrow]

I haven't seen it so much measured in fire rehab (done by temp. here) but some of the fire departments have their guys wear carbon monoxide detectors on their radios so firefighters aren't walking into potentially dangerous situations.

 

[STXmedic]

We have both the Rad57, and the Zoll X, which is capable of measuring carboxyhemoglobin. It'll be utilized at fire rehab, and any time CO exposure is suspected.

I'll admit, I haven't done enough of my own research on it yet. They teach us to subtract the COHg reading from the pulse oximetry reading, and that's our true pulse ox, but I don't know if I buy that. Especially after seeing people with COHb readings of 30% not present as I would expect a person sat'ing at 70%.

Our protocol for mandatory contact for refusal is somewhat vague. Depending on how you squint your eyes, we either have to call at 10% or 20%.

 

[Bullets]

We carry Rad-57 on all ambulances and 2 on our rehab unit, which covers half the county.

We also carry personal CO meters for each EMT when they are working, have 2 CO meters and 2 HCN meters on the rehab unit for on scene air monitoring at fires

 

[KellyBracket]

We carry Rad-57 on all ambulances and 2 on our rehab unit, which covers half the county.

We also carry personal CO meters for each EMT when they are working, have 2 CO meters and 2 HCN meters on the rehab unit for on scene air monitoring at fires

What is your protocol for using this? What #s are "must transport," or "may clear?"

 

[spnjsquad]

Sadly, my house has had to call the FD before for a malfunctioning CO detector. From what I've seen, only the FD uses them. I have personally never seen a rehab crew with them.

 

[systemet]

We use > 5% in non-smokers and > 10% in smokers as a "medically deny return to duty" during rehab. We don't have a set value mandating transport, our mandatory transport criteria are

* HR > 180 OR irregular
* CP
* Dyspnea / abnormal lung sounds
* "Significant injury"
* "Symptoms of heat stroke", including altered LOC.

Other than that, pretty much everyone gets a 10 minute break after their second bottle and oral hydration. If they remain tachycardic (>100), SpO2 < 95%, Temp > 38.0C) they get another 20 minute rest and a full assessment. If there's any concerning findings at this point, then we'd transport.

So it's more of a gestalt. While we don't have a specific value that mandates transport, I would expect to get a few angry emails if I left someone with an SpCO of 15% on scene.

Of course, these things are always depend on how much the fire department actually values its own self-preservation and contributes to assigning and enforcing a rehab sector.

From what I remember, these things are not wonderfully sensitive. There's a fairly poor correlation between SpCO and pCO.

As their expensive, we don't typically carry them on the ambulances (we have about 30), but put them on our SUVs (7 trucks).

 

[Tigger]

We have them in some of the ambulances yet half our staff have no idea that they are present. So as you can imagine, we don't have a policy on that.

I would like for use to get passive monitors to clip to our house bags. Lots of hillbilly construction here where the heating systems are not often up to code.

 

[Tigger]

We carry Rad-57 on all ambulances and 2 on our rehab unit, which covers half the county.

We also carry personal CO meters for each EMT when they are working, have 2 CO meters and 2 HCN meters on the rehab unit for on scene air monitoring at fires

What do you issue each EMT?

I'm looking at the Honeywel Gas Alert Clip to put on each bag. At 100 bucks for three years of service it seems hard not to justify it.

 

[jrm818]

One place I worked (many homes that were suspect) did this also - one on each house bag. Never had mine go off, but I know some people did...one in the ambulance IIRC. I very much appreciated that the company cared enough to buy them.

We used these, think that's what you're considering http://www.gasmonitors.com/main.cfm?sub3=84&page=prodpage&pid=30

just have to press a button every 24ish hours...easy peasy.

I almost bought one for myself at the next place I worked, as much for personal protection as for the patients. If I had been there longer I probably would have.




For the original question - I also worked at a service that bought a RAD-57. There was a protocolized number for "OK to go back to the fire" but I forget what it was - 15% maybe? I never used it at a fire, but from the literature I saw I wouldn't have trusted a normal number anyways. As I recall only abnormally high readings were of value. I did use it to screen some patients, but again didn't really consider a normal value of use. I think the ambient monitors may actually be of more value, not the least because they protect the most important person - me!

 

[Tigger]

Yup those are the ones.

 

[Handsome Robb]

About 50% of the Fire Apparatuses here have them, our supervisors have them as well and they will be co-dispatched with us to calls where it's obvious we'll need it (working fire with patients, CO alarms, any gas leak with patients, things like that) then we can also request them to the scene as needed.

I've only had to use it a handful of times but I do think it's a good piece of equipment.

There's no protocol requirement for it that I'm aware of except our Poisoning/OD protocol which says consider using it.

We use the same values as systemet, we don't rehab fire, they do it themselves. Only time we come into play on the fireground for the FFs is if they have a complaint or injury.

 

[KellyBracket]

...

From what I remember, these things are not wonderfully sensitive.

Many researchers consider the that to be the main problem as well. This can also be a problem for most any piece of diagnostic equipment as well, true. The BP cuff, for example, an often be initially misleading.

However, the CO-oximeter devices (RAD-57) are a particularly difficult issue, since many protocols call for a threshold value, or "hard number," to be used for clinical decision-making. E.g. if it's < 10% you're clear, > 15% transport. This is very concerning in scenarios such as fire rehab, where a faulty reading may clear a FF to head back into action.

A wordier version of this perspective is at Checking firefighters for carbon monoxide - recent studies, persistent concerns.

I can imagine the utility of these devices in certain scenarios, mostly in cases where the specificity would be useful.

 

[Bullets]

What is your protocol for using this? What #s are "must transport," or "may clear?"

Theres no "number". Its a tool like any other, how is the patient presenting? Since we also carry gas detectors, if our RAD-57 is reading but our CO meters arent, then who do you trust? The two gas meters with 0 readings or the Rad?

When we do rehab, <5% get O2 and continually monitored throughout the rehab cycle. If their numbers go down then they get released, if they go up then transport.

Additionally, there has been some research that says the Rad isnt particularly accurate

We started carrying Rae Systems ToxiRae 3s but have since upgraded to ToxiRae Pros. We also have HCN detectors in our rehab unit that are ToxiRae Pros. We are a RaeSystems town, so thats easier. We utilize their RaeLink system so we can cast a virtual net for air monitoring during HazMat and Fires. I have a central unit that receives signals from the ToxiRaes so i can tell what each member is reading. So if the Fire Chief, or the Treatment Area has high readings we can adjust accordingly

 

[Handsome Robb]

Theres no "number". Its a tool like any other, how is the patient presenting? Since we also carry gas detectors, if our RAD-57 is reading but our CO meters arent, then who do you trust? The two gas meters with 0 readings or the Rad?

When we do rehab, <5% get O2 and continually monitored throughout the rehab cycle. If their numbers go down then they get released, if they go up then transport.

Additionally, there has been some research that says the Rad isnt particularly accurate

We started carrying Rae Systems ToxiRae 3s but have since upgraded to ToxiRae Pros. We also have HCN detectors in our rehab unit that are ToxiRae Pros. We are a RaeSystems town, so thats easier. We utilize their RaeLink system so we can cast a virtual net for air monitoring during HazMat and Fires. I have a central unit that receives signals from the ToxiRaes so i can tell what each member is reading. So if the Fire Chief, or the Treatment Area has high readings we can adjust accordingly

at 5% you guys are treating? Thats a pretty low number especially for FFs working on the fireground. Do y'all use the finger hoods that come with the rad? ambient light can cause readings to be skewed so it's important to make sure the probe isn't being exposed to light when you're taking a reading.

I'm not targeting that at you, Bullets. after reading that it kinda seems like I was but I'm typing one handed so it's tough for me to make edits. Was meant to be a general statement from observations I've made here.

 

[Bullets]

at 5% you guys are treating? Thats a pretty low number especially for FFs working on the fireground. Do y'all use the finger hoods that come with the rad? ambient light can cause readings to be skewed so it's important to make sure the probe isn't being exposed to light when you're taking a reading.

I'm not targeting that at you, Bullets. after reading that it kinda seems like I was but I'm typing one handed so it's tough for me to make edits. Was meant to be a general statement from observations I've made here.

we dont use the hoods, but like i said, it all based on the patient. Some of our older FFs smoke, so no, they arent getting O2 based just on the number. Also depends on what the SpO2 is reading. But if a younger guy is sucking wind, has soot in the nares and is getting a 5% then yeah they are getting treatment. Also we arent seeing them in rehab until after 2 SCBA bottles so theyve been working for 1hr+

Also for us, its about air monitoring. If our air monitoring net is reading any HCN or CO above 30PPM then the FF are on SCBA air no matter what they are doing, including post fire overhaul inside the structure. Our fire officers carry Q-Raes during over for this purpose.

 

[WuLabsWuTecH]

We have a Rad-57 on each truck that has SPO2 and SPCO but not metHb.

I'm surprised that anyone has mandatory transport criteria. Our patients, if of sound mind (which I guess you could argue that high numbers may indicate they are not of sound mind) can always decide when to transport.

I have found it very useful in one situation. We had a mass-casualty of sorts where an entire house (there was a small family gathering there) had headaches. We were able to get 2 trucks out the door so I had 2 Rad57s on scene and they were a useful tool to tell me about exposures and such. But you always treat the patient and not the machine. For some reason still unknown to me to this day, dispatch did not have them leave the house so by the time we got there 20 minutes after the call (typical time in our area) we had 2 unresponsives. I don't care what the RAD57 says on them vs the other 10 people in the house, those 2 are going first!!!

After that, you still take people based on symptoms and clinical presentation, and while the Rad57 is a useful tool, you can't just take people in order of highest to lowest Rad57 reading. It did, however, help with my determination of who was going to hyperbaric vs who was going to another hospital (since I couldn't send all 12 people to the hyperbaric center that only had a capacity of 2 or 3).

As far as rehab, I make the determination based on clinical judgment whether someone is recommended to be cleared or not, but it's ultimately up to the fire department's officer in charge (along with their SOGs) if someone is cleared or not. I think one of the FDs we run with uses anything > 10 as an absolute cutoff regardless of if they have symptoms or not, but otherwise, I just give whichever FD we're working with's officer my recommendation and the SPCO number (along with the rest of the vitals). I can only recommend that someone not go back in, but I have no authority over another department's members.

Does anyone know how much these things cost anyways? I took the second Rad57 off the other truck since they weren't going to need it enroute (CO saturation doesn't change that quickly) but when I got back to the station I forgot to take one of the two out of my truck and put it in the office so the other truck could put it back in their cabinet when they got back. During truck check the next day, my Chief just about had a heart attack when he learned we were missing one--apparently they are expensive! I've heard anywhere from $2k to $10k but no definite answer.

(Yes, the crew checking out the truck that had 2 got yelled at by the chief later for not finding the second one during truck check... which was right next to the first...)

 

[Handsome Robb]

we dont use the hoods, but like i said, it all based on the patient. Some of our older FFs smoke, so no, they arent getting O2 based just on the number. Also depends on what the SpO2 is reading. But if a younger guy is sucking wind, has soot in the nares and is getting a 5% then yeah they are getting treatment. Also we arent seeing them in rehab until after 2 SCBA bottles so theyve been working for 1hr+



Also for us, its about air monitoring. If our air monitoring net is reading any HCN or CO above 30PPM then the FF are on SCBA air no matter what they are doing, including post fire overhaul inside the structure. Our fire officers carry Q-Raes during over for this purpose.

That's awesome that you guys are that proactive about wearing air. It seems like it's becoming more prevalent but I still see videos of firefights all the time in a huge cloud of smoke working off air.

As far as cost I want to say I was told they're in the 3-4k range. They used the price as a reason not to outfit every one of our units with one. 42 ambulances and that turns into a lot of money.

This guy says his department's cost is 3k at the bottom of his review then also lists out some other prices.

http://www.firegeezer.com/2008/01/17/the-rad-57-co-oximeter/

 

[Bullets]

That's awesome that you guys are that proactive about wearing air. It seems like it's becoming more prevalent but I still see videos of firefights all the time in a huge cloud of smoke working off air.

As far as cost I want to say I was told they're in the 3-4k range. They used the price as a reason not to outfit every one of our units with one. 42 ambulances and that turns into a lot of money.

This guy says his department's cost is 3k at the bottom of his review then also lists out some other prices.

http://www.firegeezer.com/2008/01/17/the-rad-57-co-oximeter/

We have a bunch of younger fire officers who are also EMTS, as well a rash of very progressive Fire Chiefs, the danger of HCN has been pushed at every major conference in the area on both sides of the service and the fire academies are teaching their recruits to stay on air. Also you see the NFPA research is suggesting that the cardiac arrests we've been dealing with may actually be a result of HCN poisoning.

If the department balks at the cost of the RAD, perhaps the price of personal single gas meters is more palpable. ToxiRae run a few hundred dollars based on options, not patient specific but allows greater safety for the crew as well

 

[Handsome Robb]

We have a bunch of younger fire officers who are also EMTS, as well a rash of very progressive Fire Chiefs, the danger of HCN has been pushed at every major conference in the area on both sides of the service and the fire academies are teaching their recruits to stay on air. Also you see the NFPA research is suggesting that the cardiac arrests we've been dealing with may actually be a result of HCN poisoning.



If the department balks at the cost of the RAD, perhaps the price of personal single gas meters is more palpable. ToxiRae run a few hundred dollars based on options, not patient specific but allows greater safety for the crew as well

That's good to hear. Seems like the new push for respiratory disease/cancer related deaths to be LODDs probably has something to do with it.

We're not fire based so we really don't need personal gas meters.

They spend money oddly here. Don't wanna put a Rad on every ambulance but we got window breaker tools this summer...the rads were too expensive for every unit but there's talk of all 42 being retrofitted with the PowerLoad system. Just spent 5 mil or so on our new dispatch center but didn't change much as far as dispatching software.